Significant Medication Error: Morphine Overdose Due to Dose Miscalculation
Penalty
Summary
A significant medication error occurred when a licensed practical nurse (LPN) administered 5 ml (100 mg) of liquid morphine to a resident, instead of the prescribed 5 mg dose. The resident, who had a history of cerebral vascular accident (stroke), diabetes, dementia, and atrial fibrillation, was dependent on staff for most activities of daily living and was experiencing respiratory distress. The nurse practitioner (NP) had ordered morphine 5 mg every hour as needed for shortness of breath, with the medication available in a concentration of 20 mg/ml. The LPN failed to correctly calculate and administer the ordered dose, resulting in the resident receiving 20 times the intended amount of morphine. The facility's medication administration protocol required two nurses to verify the amount of liquid narcotic to be given, especially when a dosage calculation was necessary. However, the LPN did not verify the dose with another nurse as required by facility policy. The error was discovered when the nurse manager noticed that the medication order had not been confirmed in the electronic chart and upon review, found that the LPN had documented administering 5 ml instead of the correct 0.25 ml (5 mg) dose. The nurse manager initially believed the resident had received 20 mg, but later calculations revealed the actual dose was 100 mg. Following the administration of the incorrect dose, the resident's condition deteriorated, with declining oxygen saturation and increased agitation. The NP was notified and gave orders to hold further morphine and monitor the resident. The family was informed of the medication error and chose not to transfer the resident to the hospital. The resident's condition continued to worsen, and he passed away a few hours after receiving the overdose. The facility's investigation identified the failure to follow the five rights of medication administration and the lack of required double-checking of the dose as the root causes of the error.
Removal Plan
- The facility completed a thorough investigation identifying the root cause that LPN-A did not follow the medication right or right dose and did not verify the dose with another nurse.
- LPN-A was placed on a leave pending the investigation.
- All nursing staff were educated on the medication order transcription process, order confirmation process, ensuring orders are confirmed and appear on the electronic medication record prior to administration, double noting of liquid narcotics to ensure correct dosing on order and in the narcotic book.
- IDT meeting was held to discuss the use of liquid narcotics in the facility vs. sublingual morphine to propose the change to the pharmacy for emergency medication kit use.